Intraocular Tumor-Associated Lymphangiogenesis A Novel Prognostic Factor for Ciliary Body Melanomas with Extraocular Extension? Ludwig M. Heindl, MD, 1 Tanja N. Hofmann, MD, 1 Werner Adler, PhD, 2 Harald L. J. Knorr, MD, 1 Leonard M. Holbach, MD, 1 Gottfried O. H. Naumann, MD, 1 Friedrich E. Kruse, MD, 1 Claus Cursiefen, MD 1 Purpose: To evaluate whether intraocular tumor-associated lymphangiogenesis contributes to prognosis of ciliary body melanomas with extraocular extension and to study its association with other tumor characteristics. Design: Nonrandomized, retrospective case series. Participants: Twenty consecutive patients enucleated for a malignant melanoma of the ciliary body with extraocular extension. Methods: Lymphatic vessels were identified using lymphatic vascular endothelial-specific hyaluronic acid receptor-1 (LYVE-1) and podoplanin as specific immunohistochemical markers for lymphatic vascular endothe- lium. Baseline tumor characteristics included intra- and extraocular tumor size, 2009 tumor, node, metastasis (TNM) classification, route of extraocular spread, tumor cell type, mitotic rate, Ki-67 proliferation-index, micro- vascular patterns and density, tumor-infiltrating lymphocytes and macrophages, and expression of human leukocyte antigen (HLA) class I and insulin-like growth factor-1 receptor. Kaplan-Meier and Cox regression analyses of melanoma-specific survival were performed. Main Outcome Measures: Prevalence of intraocular LYVE-1 + /podoplanin + lymphatic vessels and associ- ation with intraocular tumor characteristics and metastasis-free survival. Results: Intraocular LYVE-1 + and podoplanin + lymphatic vessels could be detected in 12 (60%) of 20 ciliary body melanomas with extraocular extension. Presence of intraocular LYVE-1 + /podoplanin + lymphatic vessels was significantly associated with larger intra- (P = 0.002) and extraocular tumor size (P0.001), higher TNM categories (P = 0.004), epithelioid cellularity (P = 0.016), higher mitotic rate (P = 0.003), higher Ki-67 prolifer- ation-index (P = 0.049), microvascular networks (P = 0.005), higher microvascular density (P = 0.003), more tumor-infiltrating macrophages (P = 0.002), higher expression of HLA class I (P = 0.046), and insulin-like growth factor-1 receptor (P = 0.033), but not significantly with route of extraocular spread (P = 0.803), and tumor- infiltrating lymphocytes (P = 0.069). Melanoma-specific mortality rates increased significantly with the presence of intraocular LYVE-1 + /podoplanin + lymphatic vessels (P = 0.008). By multivariate Cox regression, tumor size (hazard ratio, 14.40; P = 0.002), and presence of intraocular lymphatic vessels (hazard ratio, 8.09; P = 0.04) were strong prognostic predictors of mortality. Conclusions: Intraocular peritumoral lymphangiogenesis seems to be associated with an increased mortality risk in patients with ciliary body melanomas and extraocular extension. This association may be primarily because of an association of intraocular lymphangiogenesis with greater tumor size and increased malignancy. Financial Disclosure(s): The authors have no commercial or proprietary interest in any of the materials discussed in this article. Ophthalmology 2010;117:334 –342 © 2010 by the American Academy of Ophthalmology. Ciliary body melanomas with extraocular extension, compos- ing up to 4% of uveal melanomas, have consistently been correlated with poorer prognosis for survival. 1,2 Recently, this correlation was attributed to an increased malignancy of the intraocular tumor 1 with larger tumor dimensions, 3,4 epithelioid cellularity, 3,5 higher mitotic rates, 3 closed connective tissue loops 3,6,7 and monosomy 3. 3,8,9 Further independent predictors of melanoma-related mortality documented in 1 study in- clude gene expression profiling, 3,10 mean diameter of the 10 largest nucleoli, 3,11,12 Ki-67 immunoreactivity, 3,12 microvas- cular density, 3,13,14 number of tumor-infiltrating lympho- cytes 3,15,16 and macrophages, 3,17 and level of human leukocyte antigen (HLA) class I 3,18 and insulin-like growth factor-1 receptor expression. 3,19 Uveal melanomas may metastasize predominantly by hematogenous spread with strong hepatic tropism. 3,4 How- ever, the rare potential of lymphatic metastasis into the regional lymph nodes has been reported for patients with uveal melanoma and extraocular extension. 20,21 Tumor-associated lymphangiogenesis (i.e., outgrowth of new from preexisting lymphatic vessels) is considered as the initial step in lymphogenic metastasis for several tumors 334 © 2010 by the American Academy of Ophthalmology ISSN 0161-6420/10/$–see front matter Published by Elsevier Inc. doi:10.1016/j.ophtha.2009.06.057